doi: 10.3389/fpsyg.2017.01860
Edited by: Alemka Tomicic, Diego Portales University, Chile Reviewed by: Adelaida María A. M. Castro Sánchez, University of Almería, Spain Johannes C. Van Der Wouden, VU University Amsterdam, Netherlands *Correspondence: Gianluca Castelnuovo gianluca.castelnuovo@auxologico.it; gianluca.castelnuovo@unicatt.it † Present Address: Hester R. Trompetter, Department of Medical and Clinical Psychology, Center for Research on Psychology in Somatic Disorders, Tilburg University, Tilburg, Netherlands
Specialty section: This article was submitted to Clinical and Health Psychology, a section of the journal Frontiers in Psychology
Received: 14 October 2016 Accepted: 06 October 2017 Published: 31 October 2017 Citation: Giusti EM, Pietrabissa G, Manzoni GM, Cattivelli R, Molinari E, Trompetter HR, Schreurs KMG and Castelnuovo G (2017) The Economic Utility of Clinical Psychology in the Multidisciplinary Management of Pain. Front. Psychol. 8:1860. doi: 10.3389/fpsyg.2017.01860
The Economic Utility of Clinical
Psychology in the Multidisciplinary
Management of Pain
Emanuele M. Giusti
1, 2, Giada Pietrabissa
1, 2, Gian Mauro Manzoni
2, 3, Roberto Cattivelli
1, 2,
Enrico Molinari
1, 2, Hester R. Trompetter
4†, Karlein M. G. Schreurs
4and
Gianluca Castelnuovo
1, 2*
1Department of Psychology, Catholic University of the Sacred Heart, Milan, Italy,2Istituto Auxologico Italiano IRCCS,
Psychology Research Laboratory, Ospedale San Giuseppe, Verbania, Italy,3Faculty of Psychology, eCampus University,
Novedrate, Italy,4Department of Psychology, Health and Technology, Centre for eHealth and Wellbeing Research, University
of Twente, Enschede, Netherlands
Keywords: pain management, clinical psychology, cost-effectiveness, psychometrics, health psychology, clinical health psychology, clinical health interventions, psychotherapy
INTRODUCTION
Chronic musculoskeletal pain is the leading sources of disability worldwide, imposing an enormous
burden to both societies and healthcare systems (
Vos et al., 2012
). Direct medical expenses and
indirect costs due to losses in work productivity exceed $200 billion in the US (
Ma et al., 2014; Park
et al., 2016
) and are a major source of concern in Europe (
Breivik et al., 2013
). Mean per capita costs
vary from country to country (see Table 1), but are estimated to double the expenses for the care of
matched controls (
Gore et al., 2012; Hong et al., 2013
). Notably, their impact is directly linked both
to the severity of the condition and to the presence of mental comorbidities, and can be inflated
by concomitant opioid abuse (
Baumeister et al., 2012; Manchikanti et al., 2013; Stockbridge et al.,
2015; Rayner et al., 2016
).
In the last decades, the biopsychosocial model has attempted to answer to the growing
imperative need to identify the best practices for the prevention and treatment of chronic pain
and related conditions. Scientific research shows that clinical psychology plays a key role within
the multidisciplinary approach that is increasingly being suggested for pain management. Its
added value is revealed not only by the improvement of the patient experience, but also with
regards to economic savings and cost reduction of his care, which is an issue on which modern
health services base their strategic decisions. These benefits have been corroborated by studies
addressing psychological treatments for chronic musculoskeletal pain, which will be discussed
later. However, we argue that the work of clinical psychologists can improve the economic
sustainability of chronic pain management in all the stages of the care, from the assessment
phase to the rehabilitation period, providing a differentiated contribution depending on the
treatment course of the patient (i.e. conservative treatment, surgical intervention). In particular,
we suggest that the cost-effectiveness of chronic pain management can be enhanced employing
a psychometrically sound, computerized and integrated assessment. After the diagnostic process,
psychological techniques and interventions can be useful for pain management or, in case of
surgical interventions, to enhance their outcomes.
TABLE 1 | Direct and indirect annual cost per capita of musculoskeletal conditions.
Pain condition References Country Type of cost Cost per patient per year
Low back pain Pasquale et al., 2014 US Direct $3,607
Gore et al., 2012 US Direct $8,386
Gustavsson et al., 2012 Sweden Direct and indirect $9,781
Becker et al., 2010 Germany Direct and indirect €3,579
Hong et al., 2013 UK Direct £1,074
Osteoarthritis Pasquale et al., 2014 US Direct $5,344
Xie et al., 2016 Various countries Direct From $1,442 to $21,335
Indirect From $238 to $29,935
Gustavsson et al., 2012 Sweden Direct and indirect $77,98
Rheumatoid arthritis Pasquale et al., 2014 US Direct $4,036
Boonen and Severens, 2011 Various countries Direct and indirect €10,479
Lundkvist et al., 2008 Various countries Direct and indirect From €2,825 to €24,688
Fibromyalgia Rivera et al., 2009 Spain Direct and indirect €9,982
Knight et al., 2013 US, France, Germany Direct and indirect From $9,199 to $13,518
Pasquale et al., 2014 US Direct $1,755
ECONOMIC BENEFITS OF AN
INTEGRATED ASSESSMENT OF PAIN AND
TREATMENT OUTCOMES AND THE ROLE
OF MODERN PSYCHOMETRIC METHODS
The multidimensional evaluation of pain and its correlates is
crucial during the entire course of the care. Starting from
the initial assessment phase, the aim of the pain specialist
is to gather detailed information on pain characteristics and
to ascertain how these characteristics are intertwined with
biomedical, psychosocial and behavioral factors (
Dansie and
Turk, 2013; Aloisi et al., 2016; Castelnuovo et al., 2016a,b;
Tamburin et al., 2016
). An integrated assessment of these
aspects may have an intrinsic positive clinical effect (
Pietilä
Holmner et al., 2013
). In addition, accurate and objective
measures are important for making correct decisions and
to lead to a cost-effective management of the following
pain management intervention. Standardized measures are
fundamental for detecting the presence of contraindication for
specific pain management options (
Daubs et al., 2010
). In this
context, psychometrics may provide the tools for a reliable,
sensitive and valid assessment of pain and of the outcomes of the
treatment. Some authors advocate for the spread integrated and
computerized assessment methods which exploit the potential
of the most modern statistical models for the construction of
valid, specific and user-friendly questionnaires which can be
linked to automated dynamic pain assessment systems (
Chang,
2013; El Miedany, 2013; Slover et al., 2015
). Item Response
Theory models can be used to calibrate these tools to assess the
person’s traits in a reliable and valid manner with the lowest
possible amount of item, greatly reducing the administration
time. These methods permit to evaluate the relevant aspects
of the patient’s experience and to easily store and access the
acquired information throughout the different phases of the
treatment and in the follow-up period. Models based on these
principles have been specifically developed for musculoskeletal
pain conditions with the aim to reduce costs and first proofs of
their cost-effectiveness have been found (
Wells et al., 2013; El
Miedany et al., 2016
).
ECONOMIC UTILITY OF THE
ASSESSMENT OF THE PSYCHOLOGICAL
VARIABLES ASSOCIATED WITH THE
TREATMENT OUTCOMES IN THE
SURGICAL MANAGEMENT OF PAIN
Surgery can be an option to relieve pain in rheumatoid arthritis,
osteoarthritis and back conditions (
Boonen and Severens, 2011;
Gore et al., 2012; Xie et al., 2016
). A large number of psychological
aspects related to pain, such as anxiety, depression, cognitions,
expectations and personality traits can be considered as strong
predictors of the outcomes of these interventions (
Schade et al.,
1999; Trief et al., 2000; DeBerard et al., 2003; Kohlboeck et al.,
2004; den Boer et al., 2006; Abbott et al., 2011; Judge et al.,
2012; Block et al., 2013; Akins et al., 2015; Anderson et al.,
2015; Kunutsor et al., 2016; Alattas et al., 2017; Lindberg
et al., 2017; Mancuso et al., 2017
). Each of these factors seems
to differently affect the various outcomes of the treatment,
leading to a boost of the direct and indirect costs of the
care. Omitting to consider the psychosocial aspects which can
interfere with the surgical intervention may lead to a worst
patient experience in terms of pain intensity and quality of
life, to a failure to return to work, to an increase in opioid
consumption or to repeat other ineffective, potentially harmful
and costly treatments. In this contexts, the contribution of
a psychologist can be essential. His role is not to decide
whether an intervention should be implemented or discarded,
but to help physicians to identify the patients at risk of poor
outcomes and to suggest how the pain management strategies
could be improved. Moreover, his work can be fundamental to
prepare the patient for the surgical intervention, e.g., assessing
unrealistic expectations or providing education, and to guide
him in the post-operative period with the aim to foster his
motivation, to facilitate his discharge, and to prevent the
conditions which may cause a relapse of the symptoms and a
readmission to the hospital (
Childs et al., 2014; Louw et al.,
2014
).
THE ECONOMIC UTILITY OF CLINICAL
PSYCHOLOGY FOR PAIN TREATMENT
Several psychological treatment options have been proven to be
cost-effective and are available for the clinical management of
pain both in traditional and in new technology-based scenarios
(
Kröner-Herwig, 2009; Trompetter et al., 2014, 2015, 2016;
Veehof et al., 2016
). In a recent meta-analysis,
Pike et al. (2016)
found that psychological interventions are successful in reducing
the use of healthcare services by the patients. This finding extends
the evidence for a positive effect of psychological interventions on
pain intensity, pain disability and the quality of life of the treated
subjects (
Hoffman et al., 2007; Williams et al., 2012; Veehof et al.,
2016
).
Comprehensive
pain
programs
administered
by
multidisciplinary teams which include the contribution of
a psychologist or which use psychological techniques are
associated with a substantial reduction in both the direct and
indirect costs of the disease, with a cost saving which is estimated
between 8,500$ to 13,000$ per patient per year (
Gatchel et al.,
2003; Gatchel and Okifuji, 2006
). All the components of these
programs are fundamental for a cost-effective care of the disease
and “carving out” some of them may impair a satisfying recovery
to the premorbid productivity levels, leading to an increase in
the future use of the healthcare resources (
Gatchel and Okifuji,
2006; Gatchel and Mayer, 2008
). Moreover, these programs
may be enhanced providing intensive psychological therapies
for the management of pain. The research is increasingly
showing that these interventions are highly effective and lead to
considerable cost savings. A group treatment for musculoskeletal
pain sufferers based on cognitive behavioral principles resulted
in additional 0.0325 Quality Adjusted Life Years (QALY) with
respect of the control condition, with an incremental cost per
QALY of £5,786 (
Taylor et al., 2016
). Various RCTs evaluated
the cost-effectiveness of group cognitive behavioral approaches
for chronic low back pain, with estimates of additional cost
per QALY ranging from £1,786 to $7,197 (
Linton and Nordin,
2006; Lamb et al., 2010; Norton et al., 2015
). An integrated care
program for sick-listed back pain patients based on a workplace
intervention and graded activity was found to provide
work-related economic savings in the amount of £5744 (
Lambeek et al.,
2010
), but graded activity was found to be less cost-effective
than exposure in vivo in another trial (
Goossens et al., 2015
).
Non-significant effects were found for a CBT program added to
inpatient rehabilitation for chronic low back pain (
Schweikert
et al., 2006
). With regards to the other syndromes, a
telephone-delivered CBT for chronic widespread pain sufferers provided
a 0.097 additional QALY with respect to a program of tailored
exercise, with an incremental cost per QALY of £5917 (
Beasley
et al., 2015
), an internet-delivered Acceptance and Commitment
Therapy program for fibromyalgia patients provided cost savings
which exceeded the costs of the treatment 2 months after its
conclusion (
Ljotsson et al., 2014
) and a psychoeducational
intervention for the same syndrome resulted in 0.12 additional
QALY with respect to control (
Luciano et al., 2013
). Although a
systematic evaluation of the cost-effectiveness of all the available
programs is beyond the scope of this article, it is established
that the costs of various psychological treatments are rapidly
overtaken by direct and indirect savings. However, clinical
psychologists are not required to indiscriminately implement
their therapies. On the contrary, their role is to help the pain
management team to identify the characteristics of the patient
and to tailor their techniques accordingly. The importance
of tailoring the interventions has been long advocated in the
literature and some evidence of the benefit of such an approach
the have been provided (
Turk, 1990; Turk et al., 1996, 1998
).
In addition, in the clinical practice, the psychologist and the
multidisciplinary pain team usually face very complex conditions
accompanied by physical or mental comorbidities, which may
prevent the use of standardized treatments. The future of the
clinical psychology and of the biopsychosocial approach in
the field of pain management seems therefore to reside in
the possibility to deliver integrated interventions which are
personalized in order to be more effective and, at the same time,
less expensive (
Castelnuovo, 2010a,b; Castelnuovo et al., 2016c
).
AUTHOR CONTRIBUTIONS
All authors listed have made a substantial, direct and intellectual
contribution to the work, and approved it for publication.
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Conflict of Interest Statement: The authors declare that the research was
conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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